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Technically Correct Fundoplication

Technically Correct Fundoplication. David W Rattner,MD. Patient Selection. Body Habitus Size of Hiatal Hernia Type of symptom Reoperation? Motility disorder. Principles of Antireflux Surgery. Restoration of intra-abdominal esophagus Reconstruction of the diaphragmatic hiatus

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Technically Correct Fundoplication

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  1. Technically Correct Fundoplication David W Rattner,MD

  2. Patient Selection • Body Habitus • Size of Hiatal Hernia • Type of symptom • Reoperation? • Motility disorder

  3. Principles of Antireflux Surgery • Restoration of intra-abdominal esophagus • Reconstruction of the diaphragmatic hiatus • Creation of the fundoplication

  4. Technical Points • Use 5 mm ports • Know where the vagi are • Routine: • crural closure • short gastric division • secure wrap to esophagus • Dilator decreases post op dysphagia rate • LOOSE FUNDOPLICATION!

  5. Know where the Vagi are! Posterior Window

  6. “Just Right” Crural Closure

  7. Re-herniation is the most common cause of failure! • Reconstruction of the diaphragmatic hiatus • Failure to reconstruct • Reinforcement with prosthetic material

  8. Tight Fundoplication

  9. Wrap looks tight!

  10. Tight and Slipped Fundoplication

  11. Incorrect Wrap Construction

  12. When is a Nissen the wrong choice for fundoplication? • Need for fixation to diaphragm-PEH • Severely disordered peristalsis • Pt who will need to vomit • Adjunct to myotomy

  13. Toupet Procedure indications • Best reserved for special circumstances • Adjunct to myotomy • Patient will need to vomit • Very poor esophageal peristalsis • Ideal for Paraesophageal Hernia Repair • Multiple points of fixation

  14. Toupet Fundoplication: Gastropexy

  15. IntraOperative Challenges • Unsuspected Hepatomegaly • Portal Hypertension • “Short Esophagus” • Too much fat! • ? Chronic Pancreatitis

  16. video

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